global health research: a perspective from the south

GLOBAL HEALTH RESEARCH:A PERSPECTIVE FROM THE

SOUTH

David SandersDirector: School of Public Health

University of the Western Cape

Member of Global Steering GroupPeoples Health Movement

Member of WHO Health Systems Research Task Force

Presented at the Conference on Global Health Research inBergen, Norway, 21-22 September, 2004

Outline of Presentation

Progress in global health 1980-2004

Role of globalisation, health sector reform and HIV/AIDS in weakening health systems in the South

Refocusing of research to address this context

with examples from South Africa

Key responses required

Progress in Global Health

Life expectancy – increases from 46 years in 1950s to 65 years in 1995

Child deaths – reduced from projected 17.5 to 11m per year

Substantial control of poliomyelitis, diphtheria, measles, onchocerciasis, dracunculiasis through immunisation and disease control programmes

Decline in cardiovascular disease in males in industrialised countries

Growing inequalities in global health

40

60

80

100

120

140

160

1960 1981 1999

IMR decline(Percent

)

1960-1981

1981-1999

World 38.5 26.9

SSA 19.2 15.1

IMR

World

SSA

UNICEF: State of the World’s Children

U5MR in Sub-Saharan Africa

0

50

100

150

200

250

World SA Kenya Swaziland Zimbabwe Botswana

1960 1990 2001

The State of the World’s Children 2003. UNICEF

1980s

Mixed progress in

implementing health policies

Progress in Implementing PHC Programme Elements

(Source: WHO 1998)

Selective Primary Health Care“Child Survival and Development Revolution”

Growth MonitoringOral Rehydration TherapyBreast FeedingImmunisation

Family PlanningFood SupplementsFemale Education

1990s: progress reversed

Inequitable globalisation, Health sector “reform”, and

HIV/AIDS

result in slow progress and reversals.

The debt crisis & structural adjustment:

A crucial development in the current phase of globalisation…

External debt

Structural Adjustment Programmes: the main components

Cuts in public enterprise deficits

Reduction in public sector spending & employment

Introduction of cost recovery in health and education sectors

Phased removal of subsidies

Devaluation of local currency

Trade liberalisation

“The majority of studies in Africa, whether theoretical or empirical, are negative towards structural adjustment and its

effects on health outcomes”

(Breman and Shelton, WHO CMH WG6, 2001)

The global growth of poverty

Global distribution of income

The Health System, its financing and its human

resources

Health expenditure

Expenditure as % of GDP

1990

Expenditure as % of GDP

1996-1998

46 High income countries (none in Africa)

5.3% 6.4%

93 Middle income countries (22 in Africa)

2.6% 3.2%

34 Low income countries (29 in Africa)

0.9% 0.8%

World 4.7% 5.6%

(Source: UNDP Human Development Report, 2000)

Actual amounts of per capita public health expenditure in Africa

Amount in USD Number of countries

> USD 60 6

> USD 34 – USD 60 3

USD 12 – USD 34 10

< USD 12 27

No data 7

(Source: Human Development Report, 2000)

Health system ‘reform’:

Aim : Improving the performance of the civil service

decentralisation of management responsibility and/or provision of health

improving functioning of national ministries of health

broadening health financing options

introducing managed competition between providers of clinical & support services

working with the private sector

Health personnel / population ratios

Doctors 31 of 53 African countries

have < 32 doctors / 100,000 people,

17 countries < 10 doctors / 100,000 people

Nurses 41 countries have < 135

nurses/100,000 people,

17 countries < 50 nurses / 100,000 people.

Source: UNDP, 2000

Doctor/100,000

Nurse/100,000

World 122 248

OECD 222 --

LDCs 70 91

SSA 32 135

Health personnel vital, consume between 60 – 80% of recurrent public health expenditure (WB, 1994).

Health professional migration from Africa

Between 1985 and 1995, 60% of Ghana’s medical graduates left

During the 1990s Zimbabwe lost 840 of 1,200 medical graduates

In 1999, 78% of doctors in South Africa’s rural areas were non-South Africans

2,114 South African nurses left for the UK during 2001

International migration—winners & losers

Using the conservative figure of US$ 20,000 to train a medical doctor, Zimbabwe lost US$ 16.8 million through the loss of 840 doctors.

Using the same conservative estimate Nigeria incurred a loss of US$ 420 million due to the migration of 21,000 physicians to the United States.

However, if the UNCTAD figure of US$ 184,000 per professional is used to calculate savings, the United States saved US$ 3.86 billion.

Global HIV prevalence 40 million people around the

world live with HIV - more than the population of Poland.

Nearly two-thirds of them live in Sub-Saharan Africa, where in the two hardest hit countries HIV prevalence is almost 40%.

The global HIV/Aids epidemic killed more than 3 million people in 2003

there are emerging and growing epidemics in China, Indonesia, Papua New Guinea, Vietnam, several Central Asian Republics, the Baltic States, and North Africa.

The AIDS debate, BBC News

Collapsing public health systems resulting from …

Declining per capita health spending reducing Health personnel numbers and morale Drug availability Transport for outreach & supervision

Promotion of the private sector through “health sector reform”

HIV/AIDS affecting and infecting health personnel

… reversing previous gains in PHC implementation

Global Immunization 1980-2002, DTP3 coverageglobal coverage at 75% in 2002

2023 25

3744

4852

5664

6975 72 71 72 74 75 75 75 74

7174 74 75

01020

3040506070

8090

100

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Global Central Europe, CIS

Industrialized countries East Asia and Pacific

Latin America and Caribbean Mid-East and N Africa

South Asia Sub-Saharan Africa

Source: WHO/UNICEF estimates, 2003

Collapsing public health systems need to

implement more complex interventions and

programmes

For example, universal access to ART would need at least:

Information dissemination & encouragement to undergo VCT

VCT: Pretest counseling Testing & test interpretation Post-test counseling

Ensuring supplies of testing equipment & drugs

Administration of appropriate treatment: Monitoring of immune status Recognition & treatment of opportunistic infections

Nutritional & social support

¶ For 3 million people, most of whom are in poor countries¶ For 500,000 people in South Africa

Each step requires enough personnel with a range of skills

Key focus areas for health research

Research on health systems, particularly on operational aspects and on evaluation

Research on health determinants (local and global) with an equity lens

Case studies of comprehensive, community-based approaches

How well are researchers meeting the challenge?

Describe the problem

Explore the contextual factors

Select possible interventions

Test interventions

Identify risk factors

Formulate public health interventions

Assess efficacy public health interventions

Assess effectiveness public health interventions

Research steps in the development and evaluation of public health interventions

De Zoysa et al, Bull WHO 1998, 76:127-133

Nutrition Engineers

As well as researchers asking “what, why, where, and who?”

We should be asking “How?”

Berg A Sliding toward nutrition malpractice: time to reconsider and redeploy Am J Clin Nutr 1993

Classification of Articles in PUBMED 1994-2002, SAJCN 1998 – 2002 (Keywords: Nutrition, South Africa)

  Food Science

Nutrition Science Efficacy Policy

  Clinical Population (includes surveys)

Number of Articles

5 81 54 25 25 10 9

Percentage of Articles

2% 31.3% 20.8% 9.7% 29% 4% 4%

Total Articles

259 

Effectiveness

Operational Evaluation

EXAMPLES OF EFFECTIVENESS RESEARCH

Research for Service Development and Health Promotion

MT. FRERE HEALTH DISTRICT

Eastern Cape Province, South Africa

Former apartheid-era homeland

Estimated Population: 280,000

Infant Mortality Rate: 99/1000

Under 5 Mortality Rate: 108/1000

INTEGRATED NUTRITION PROGRAMME

• PRIMARY PREVENTION –Address underlying socioeconomic and environmental causes

• SECONDARY PREVENTION – Regular Growth Monitoring with Nutrition Promotion & Supplementation

• TERTIARY PREVENTION – WHO 10-Steps Protocol for the Management of Severe Malnutrition

STUDY SETTING:PAEDIATRIC WARDS

Nurses have the main responsibility for malnourished children

Per Ward: 2-3 nurses and 1-2 nursing

assistants on day duty, and 2 nurses on night duty 10-15 general paediatric

beds and 5-6 malnutrition beds

Implementation Cycle

Capacity Development

Advocacy

Teambuilding

Analysis

Situational Assessment

Planning

Implementationand Management

EvaluationPolicy

CASE FATALITY IN RURAL HOSPITALS (Former Region E)

PRE-INTERVENTION CFRs

Mary Terese 46% Sipetu 25%Holy Cross 45% St Margaret’s 24%St. Elizabeth’s 36% Taylor Bequest 21%Mt. Ayliff 34% Greenville 15%St. Patrick’s 30% Rietvlei 10%Bambisana 28%

WHO 10-STEPS PROTOCOL – Nutrition component of hospital level IMCI

Step 1 Treat/prevent hypoglycaemia

Step 2: Treat/prevent hypothermia

Step 3: Treat/prevent dehydration

Step 4: Correct electrolyte imbalance

Step 5. Treat/prevent infection

Step 6. Correct micronutrient deficiencies

Step 7. Cautious feeding

Step 8. Catch-up growth

Step 9. Stimulation, play and loving care

Step 10. Preparations for discharge

Implementation Cycle

Capacity Development

Advocacy

Teambuilding

Analysis

Situational Assessment

Planning

Implementationand Management

EvaluationPolicy

Comparison of recommended and actual practices inMary Theresa and Sipetu hospitals and perceived barriers

to quality of care of malnourished children

SITUATIONAL ANALYSIS IMPLEMENTATION

Recommended practice  

Practice prior to intervention

Perceived barriers to quality care

Programme intervention

Changes reported at follow up visits

Step 1: Treat/prevent hypoglycaemia  Feed every 2 hours during the day and night. Start straight away.

Children were left waiting in the queue in the outpatient department and during admission procedures. In the wards, they were not fed for at least 11 hours at night   Hypoglycaemia not diagnosed

Lack of knowledge about risks of hypoglycaemia  Lack of knowledge about how to prevent it Shortage of staff especially during the night No supplies for testing for hypoglycaemia

Training to explain why malnourished children are at increased risk  Training on how to prevent and treat hypoglycaemia Motivated for more night staff in paediatric wards  Motivated the Department of Health to provide resources (10% glucose and Dextrostix.)

Malnourished childrenfed straightaway and 3 hourly during day and night.  The number of night staff was increased Dextrostix and 10% glucose obtained

WHO 10-STEPS TRAINING – Mt. Frere District, Eastern Cape

Developed as part of a District-Level INP

Training & Implementation from March 98 to Aug 99

Two formal training workshops for Paeds staff

On-site facilitation by nurse-trainer

Adaptation of protocols – Now have Eastern Cape Provincial Guidelines

10-STEPS EVALUATION RESULTS

Major improvements in the care of severely malnourished children:

Separate HEATED wards 3 hourly feedings with appropriate special formulas

and modified hospital meals Increased administration of vitamins, micronutrients

and broad spectrum antibiotics Improved management of diarrhea & dehydration

with decreased use of IV hydration Health education & empowerment of mothers

10-STEPS EVALUATION RESULTS

Problems still existed: Intermittent supply problems for vitamins and micro-

nutrients Power cuts – no heat Poor discharge follow-up Staff shortage, of both doctors and nurses, and

resultant low morale

CHANGES IN CFRs IN RURAL HOSPITALS

CHANGES IN CFRs IN HOSPITALS

0102030405060

PE

RC

EN

TA

GE

S

1998-1999

2000-2001

2002

2003

Follow-up research seeks to answer the following questions:

Why, with the same in-service training, do some hospitals achieve improved care in the management of severe childhood malnutrition, and others do not?

  What are the key factors that constrain and facilitate

successful implementation of the WHO treatment guidelines?

What are the most effective actions necessary to replicate successful performance in poorly performing hospitals or new settings?

How can training and/or support be improved to overcome potential constraints and allow facilitating factors to flourish?

EVALUATION OF FEASIBILITY OF IMPLEMENTING 10 STEPS

STEP 10 OF THE IMCI MALNUTRITION PROTOCOL

Giving Nutrition Education to caregivers by health staff

Planning Follow- up of the child at regular intervals post discharge

OBJECTIVES

To determine Household Food Security(HHFS), caregiver knowledge & factors associated with malnutrition

To look at the rate of recovery & health status at 1 month & 6 month post discharge

STUDY POPULATION

POST DISCHARGE HOME VISITS(HV) At 1 month (n) = 30 At 6 month (n) = 24

Average No. of people 8

Average No. of children < 6 2.5

Female Headed HH 40 %

Residing in mud houses 82 %

Subsistence Crop Production 83 %

Livestock keeping 90 %

Average family income R550

DEMOGRAPHIC & SOCIO-ECONOMIC FACTORS

76% of caregivers had <9 years education 78% of caregivers were literate

76% remembered key messages about food fortification

71% of caregivers unable to implement acquired knowledge of feeding practices

CAREGIVER KNOWLEDGE OF NUTRITION

STAPLE FOOD INVENTORY LIST

Samp / Maize Beans Maize Meal Flour Rice Sugar Soup Tea / Coffee Milk Oil Peanut Butter Eggs

No. of food items in HH Cupboard

% of HH

0 7

1 – 4 40

5 - 8 30

9 - 11 23

HOUSEHOLD SOURCE OF INCOME

PENSION GRANT 40 % MIGRANT LABOURERS 25 % NO INCOME FAMILIES 20 % DOMESTIC WORKERS 15 % CHILD SUPPORT GRANT (CSG) 0 % ANTI POVERTY PROGRAMME 0 %

CSG – Children aged 0-9 years in families earning less than

R800 per month eligibleCSG - currently R160

Implementation Cycle

Capacity Development

Advocacy

Teambuilding

Analysis

Situational Assessment

Planning

Implementationand Management

EvaluationPolicy

Advocacy Component

Presentation of data to Government Commission on Social Welfare

Newspaper articles on malnutrition and child welfare Partnership with ACESS resulted in TV documentary – ‘Special

Assignment’ – elicited unexpected response from both public and government

Minister of Social Development visited Mt Frere and ordered mobile team in to process CSGs

Questions in Parliament re child welfare Recent ‘Sunday Times’ articles on child malnutrition in

Eastern Cape Massive Child Support Grant Campaign in E. Cape, October

2002

No of Poor Children (0-6) and No. of Children Receiving CSG in Oct 2002

0

200

400

600

800

1000

1200

KZN EC L NW MP GT FS WC NC

Nos

of C

hn ('

000s

)

No. chn (0-6) in poverty No. of CSG benefs.

Sources of Data for these graphs:

Grant Voucher Uptake: SOCPEN daily record Oct 2002

Poverty Levels: Streak (2002). IDASA. Using a poverty line of R400 per capita per month (in ‘99 terms)

Population: Census 1996. Stats SA., in T. Guthrie, UCT & ACESS, Feb. 2003

EMPTY STOMACHS: Year-old Samkelo is one of nine children that his jobless grandmother, Nofuduka Mbulawe, has to feed

Picture: Richard Shorey

Sunday, September 22 2002

Starving to death on arable land Poverty is killing children in the Eastern Cape. But breaking out of its grip is no easy task, write Thabo Mkhize and Heather Robertson

A nutrition study by the University of Western Cape showed that Samkelo is one of the more fortunate - 166 babies at 11 hospitals in the northeastern district have died of malnutrition

ONE-year-old Samkelo Mbulawe has only a tattered blanket to cover his distended stomach and flaking skin. He has just returned home after two months in the Mount Ayliff Hospital where he was treated for kwashiorkor, a form of malnutrition.

Available January 10, 2004 from University of Cape Town Press

Online ordering andprepublication proofs

available at:http://web.idrc.ca/ev.php?ID=45682_201&ID2=DO_TOPIC

“Determinants” research: a global example

Assessed G8 health/development commitments 1999-2001 summits with respect to three criteria:

1. Have the G8 lived up to the commitment?

2. Was the commitment adequate, when measured against the need addressed?

3. Was the commitment appropriate, or was it, e.g., rooted in a paradigmatic economic orthodoxy that may actually undermine determinants of health?

What we found:

Promises kept: 10 *

Promises broken: 17 *

* Figures changed since book went to press.

Promises kept

+Global Fund to Fight AIDS, Tuberculosis and Malaria was established (‘primed’ with US $1.3 billion initial contributions)

+Agreement reached (August 2003) on flexibility in TRIPS to ensure access to essential medicines (although considerable uncertainty still surrounds implementation)

Promises broken Reductions in AIDS, tuberculosis and malaria mortality highly unlikely to

meet targets set in 2000

“Strong” national health systems not being supported (G7 ODA for health actually declined)

“Determinants” research: a local example – The Cape Town Equity Gauge

AIM OF PROJECT

To Decrease Inequities in the distribution of Public Health Services and other Basic Services in Cape Town

Match Service Resources according to Need for services in Cape Town

Equity Gauge5 Pillars

Measurement

Advocacy

Community Participation

Resource Allocation Framework

Implementation

Measurement

Assess Health Needs Population

Population Dependent on Public Services Other Measures of Need (Diseases, Socio-economic)

Weighted Dependent Population Assess Resources

Staff, Equipment, Drugs, Supplies, Utilities Finances (Operating Budget)

Compare Resources to Need Establish Equity Amount Assess level of Inequity

Infant Mortality Rate (IMR)

0

10

20

30

40

50A

thlo

ne

Bla

auw

berg

Cen

tral

Hel

derb

erg

Kha

yelit

sha

Mitc

hells

Pla

in

Nya

nga

Oos

tenb

erg

SP

M

Tyg.

Eas

t

Tyg.

Wes

t

Reg

ion

HIV prevalence 2000 (estimates)

0%

2%

4%

6%

8%

10%

12%A

thlo

ne

Bla

auw

ber

g

Cen

tral

Hel

der

ber

g

Kh

ayel

itsh

a

Mit

chel

lsP

lain

Nya

ng

a

Oo

sten

ber

g

So

uth

Pen

insu

lar

Tyg

erb

erg

Eas

t

Tyg

erb

erg

Wes

t

% Households below poverty line

0%

20%

40%

60%At

hlon

e

Blaa

uwbe

rg

Cent

ral

Held

erbe

rg

Khay

elits

ha

Mitc

hells

Plain

Nyan

ga

Oost

enbe

rg SP

M

Tyge

rber

gEa

st

Tyge

rber

gW

est

TOTA

L

-30,000,000

-20,000,000

-10,000,000

0

10,000,000

20,000,000

30,000,000A

thlo

ne

Bla

auw

berg

Cen

tral

Hel

derb

erg

Kha

yelit

sha

Mitc

hells

Plai

n

Nya

nga

Oos

tenb

erg

Sou

thPe

nins

ula

Tyge

rber

gEa

st

Tyge

rber

gW

estR

an

ds

Inequity in Public Primary Care Expenditure Zero line represents an average

equitable expenditure

District Health Information SystemsThe South African Experience

Developing a Routine District Health Information System

andConducting Research on Information

Systems

Information Systems Research Action Research on Developing a Basic District

Health Information System Development of an Information Audit tool Development of Policies and Procedures to ensure

Accuracy of Routinely Collected Data Development of a Hospital Information System

Morbidity, mortality, service coverage, efficiency Development of a Community Based Information

System Child Health Monitoring community health workers programme

Enhancing Capacity for Public Health Research and Action

Responses from SoPH

Education Continuing education Post-graduate education Programme-based training

Research Health systems research, focusing on

implementation and its evaluation Service development

Focused on key programmes and systems components

Matrix of programmes and systems components

  Systems/Strategies

Programmes

HRD Health information

Health Management

Health promotion

HIV/TB x x    

Nutrition x   x x

MCH        

School Health       x

Water & Sanitation

  x   x

Continuing Education - Short Courses

24 Winter & Summer Schools About 40 courses offered: i)Reorientation

ii)Systems and management related iii)Specific Programmes iv)Research

1-3 weeks duration >6,000 health workers graduated Good evaluation from participants and WHO

School of Public Health

University of the Western Cape

Winter School 2001: 2-20 July 2001

Formal Postgraduate Education

Masters in Public Health Adapted to working students and small

teaching staff Part time teaching blocks of classroom

learning and practice-based assignments at workplace

Multiple entry and exit points Adapted for Distance Learning

Diagram Illustrating the School of Public Health’s Configuration of its Postgraduate Certificate, Postgraduate Diploma and Masters In Public Health (University of the Western Cape) for 2003

Modules

ENTER

Possible streams for Post Graduate Diploma: General (consisting of Health Management & Health Promotion), Human Resource Development, Health Information Systems, Health Promotion, Health Management, Health Systems Research, Nutrition

Masters in Public Health 2 Selectives (20 credits each) Mini-Thesis (40 credits) * all credits at NQF level 8

Postgraduate Certificate Modules

Understanding Public Health

Health Development and

Primary Health Care I

Health Systems Research I

Measuring Health & Disease I

Health Management I

Health Promotion I

(20 credits for each module at

NQF Level NQF level 6)

Entry Point

Postgraduate Diploma Modules Understanding Public Health Health Development and Primary Health Care II Measuring Health & Disease II

Stream Module I Stream Module II Elective Module

Composite exam

(20 credits for each module at NQF level 7)

Enter

Graduate

Postgraduate Diploma in Public Health (120 credits)

Masters in Public Health ( 200 credits)

Graduation

Post-graduate Certificate in Public Health (120 credits)

Student profile cont.:Students come from twelve countries:

South Africa (101) Namibia (18) Zambia (9) Zimbabwe (1) Uganda (2) Tanzania (3) DRC (1)

Botswana (1) Niger (1) Peru (1) Greece (1) China (1) Northern Ireland (1) Canada (1)

Virtually all health professions; many nurses, district managers & facility managers

In conclusion Health systems in SSA are in crisis. HIV/AIDS

accentuates this. Research can improve effectiveness and equity

by prioritising: HSR especially implementation issues Equity issues at local and global levels Advocacy based upon evidence

Key responses must include: Increased investment in HSR and equity orientated

research Increased investment in enhancing capacity of

Southern institutions (incl. equitable collaboration/partnerships with Northern institutions)

Support for innovative teaching and research efforts